Essay Elements:
- One to three pages of scholarly writing in paragraph format, not counting the title page or reference page
- Brief introduction of the case
- Identification of the main diagnosis with supporting rationale
- Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out
- Diagnostic plan with supporting rationale or references
- A specific treatment plan supported by recent clinical guidelines
- Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric.
- Citations: At least two high-level scholarly reference in APA per post from within the last 5 years
PATIENT DASHBOARD
Patient Name: Ann Tomlin
- Age: 33
- Sex assigned at birth: female
- Gender identity: female
- Pronouns: she/her/hers
- Language for medical communication: English
“What brings you in today?”
“I have been having some problems the past year or so with cramps during my period. I am not used to it and am missing two or three days of work every month because of it.”
It sounds as if this pain is really affecting your life,” you empathize. “Can you tell me if you have any other symptoms during your periods?”
“Sometimes I have diarrhea as well, but that is only for one day at the beginning. But for the entire time, I have my period I am just so exhausted.”
What are the risk factors for primary dysmenorrhea?
A. High levels of stress
E. Smoking
F. Younger age
HISTORY 1
Physical Exam
Vital signs:
- Pulse is 82 beats/minute
- Respiratory rate is 16 breaths/minute
- Blood pressure is 115/74 mmHg
- Weight is 65.8 kg (145 lbs)
- Height is 165 cm (65 in)
Head, eyes, ears, nose, and throat (HEENT): Normal-sized thyroid gland without palpable nodules or tenderness.
Pulmonary: clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm without murmur.
Abdominal: Normal bowel sounds. Non-tender to palpation over the abdomen but slightly tender in the suprapubic area. No rebound or guarding.
When you have finished the exam, you explain to her, “I think Dr. Barnett wants to do an exam of your uterus and pelvis, so please wait here while I go get him. Would you like a chaperone to join us in the room as well?.” She declines the chaperone, and you step out.
What are always abnormal findings on a pelvic exam?
A. 12-week-size uterus when not pregnant
D. Non-mobile uterus
HISTORY 2
PELVIC EXAMINATION
After checking with Ms. Tomlin if she is okay with you helping do the pelvic exam, you both help adjust the table to the lithotomy position and ask her to lay back when she is ready. Dr. Barnett gives you gloves and you sit down on the stool. You ask Ms. Tomlin to relax her legs without pushing them aside, you vocalize each step of your exam before touch, and you gently insert the speculum at an angle to allow for maximum comfort, readjusting as you continue to insert the speculum. As you describe what you are doing, you also ask her to tell you if anything is painful during the exam.
Pelvic Exam
Speculum exam: Minimal white non-foul-smelling discharge in the vagina. No abnormal lesions on the cervix. No other lesions in the vagina.
Bimanual exam: The uterus feels enlarged, about 10 to 12 weeks in size, but nontender and easily mobile. The ovaries are normal size and nontender on exam.
When you are done you say, “Ms. Tomlin, why don’t you go ahead and get dressed, and then Dr. Barnett and I will come back to explain everything.”
SUMMARY STATEMENT
When Dr. Barnett asks why you think she may have abnormal uterine bleeding, you elaborate: “I think that having to use so many pads and tampons per day would be abnormal, as well as passing clots. Her periods are regular every 29 days and menstrual cycles normally last 21 to 35 days. She has no bleeding between periods, it just seems heavy but not irregular.”
Ann Tomlin is a 33-year-old G2P2 cisgender female with several months of dysmenorrhea that causes her to miss work. She has associated menorrhagia, fatigue, and abdominal bloating. She also reports intermittent diarrhea and dyspareunia. Physical examination reveals an enlarged, mobile, non-tender uterus.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
- Epidemiology and risk factors: 33-year-old female, G2P2
- Key clinical findings about the present illness using qualifying adjectives and transformative language:
- Associated menorrhagia
- Associated fatigue and abdominal bloating
- Intermittent diarrhea
- Dyspareunia
- Enlarged, mobile, non-tender uterus
- Symptoms severe enough to cause her to miss work
DIFFERENTIAL DIAGNOSIS 1
A. Adenomyosis
C. Chronic pelvic inflammatory disease
E. Endometriosis
F. Fibroids
SCIENCES EXCELLENCE IN ACTION
Dr. Barnett suggests moving on to discuss the concern for abnormal uterine bleeding you uncovered during your interview.
As you consider the potential causes, Dr. Barnett asks you to consider how the physiology core concept of regulation of reproduction may impact Ms. Tomlin’s working diagnosis.
“Successful reproduction requires appropriate sexual maturation (puberty), menstrual cycling and ovulation, production of gametes capable of fertilization, recognition of early pregnancy, pregnancy, parturition, and lactation,” says Dr. Barnett. “Understanding the foundational physiology that underlies these processes is important to understanding the diagnosis and managing abnormalities within the reproductive organs. With that knowledge, we can separate explanations for abnormal bleeding as due to either structural or nonstructural issues.”
|
Structural |
Nonstructural |
|
Polyps Adenomyosis Leiomyoma Malignancy and hyperplasia |
Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not otherwise classified |
Now we can look at the additional historical or exam factors listed above and see how they might steer your differential diagnosis towards either category.
- Bleeding that occurs after intercourse could be either structural or nonstructural. The differential for bleeding after intercourse would include conditions affecting the tissue of the vagina or cervix. This could be cervical cancer, endometrial or cervical polyp, vaginal atrophy, or cervicitis from an STI. Both vaginal atrophy or STI causes could be considered nonstructural as one is due to a loss of hormones and the other infectious, though ultimately the final problem is a defect in cervical or vaginal skin.
- Labs showing elevated LH/FSH ratios are likely a nonstructural cause. An abnormality in the LH/FSH ratio points towards a problem in the hormonal regulation of menstruation. With this finding, one should consider PCOS as a likely cause of the lab abnormality and bleeding irregularity.
- With patients over the age of 50, many have already entered menopause. If so, there should be no hormonal factors to cause growth and sloughing of the endometrium, so structural causes are more salient. When there is postmenopausal bleeding, the endometrium is growing under its own influence and this raises concern for endometrial cancer.
- A soft, boggy, nontender uterus on palpation points towards a structural cause. A palpable uterus on exam may indicate that there is a factor causing enlargement of the uterus. Conditions to consider with this physical exam finding include adenomyosis and pregnancy. If you primarily palpated an enlarged uterus, that was mobile, possibly irregular, or mildly tender, then leiomyoma (fibroids) would move higher in your differential.
- A history of postpartum bleeding with all deliveries is characteristic of a nonstructural cause. Recurrent bleeding after delivery raises concerns for a bleeding disorder, such as Von WIllebrand disease.
CONTINUED DISCUSSION
After reviewing several possible explanations for her abnormal uterine bleeding, Dr. Barnett asks what you suspect may be the cause.
“I feel that it is likely Ms. Tomlin has fibroids. It is also possible she has adenomyosis, since her uterus is symmetrically shaped, or all of her fibroids could be intramural. Her sexual and reproductive history makes chronic pelvic inflammatory disease less likely. Endometriosis could be the diagnosis as well. Since endometriosis is often diagnosed with surgery, it is reasonable to empirically treat for fibroids initially. Then on subsequent visits, if the symptoms are not improved, a consult to gynecology for surgical consideration would be warranted.”
Nodding, Dr. Barnett responds, “Ms. Tomlin’s history and exam certainly can point toward the presence of fibroids. In fact, fibroids would explain both the dysmenorrhea she has been experiencing and the abnormal uterine bleeding. Remember that the underlying physiologic mechanism of fibroid development is related to the regulation of reproductive processes primarily by the hormones estrogen and progesterone under stimulation by LH and FSH.”
Dr. Barnett explains, “The normal cycle of progesterone and estrogen levels that occurs every 28 days prepares and supports the process of reproduction. The reproductive structures (ovaries, uterus, endometrium) respond to the fluctuating hormone levels as they prepare the egg (ovaries) and the environment to accept an egg and support the growth (uterus and endometrium) of a fertilized egg or start the process all over again when the egg is not fertilized.”
Dr. Barnett continues, “If we are correct in our hypothesis that Ms. Tomln has fibroids, the smooth muscle cells of her uterus have responded to this hormone cycle by producing abnormal uterine smooth muscles that have organized in clumps of cells. Over many years, the fibroids have enlarged and now affect the structure of her endometrium and uterus, which presents clinically as pain and/or abnormal uterine bleeding. Knowing that fibroid development is not an issue of the underlying endocrinologic reproductive system but a response of uterine cells to the normal cycle of hormones helps us to target possible interventions.”
DIAGNOSTIC TESTING
Having discussed possible explanations for Ms. Tomlin’s dysmenorrhea and abnormal uterine bleeding, Dr. Barnett agrees with your assessment that she has fibroids. He says, “Let’s talk about what studies should be conducted at this point to rule out other medical conditions, such as adenomyosis, and to confirm our diagnosis. Then, we can discuss our recommendations with Ms. Tomlin.”
A. Complete blood count
C. Human chorionic gonadotropin
E. Pelvic ultrasound
F. Thyroid-stimulating hormone
INITIAL PLAN
You and Dr. Barnett go back in the exam room and he explains the diagnosis to Ms. Tomlin, adding, “I was wondering if you could tell me how much this affects your life?”
“I think my periods are pretty heavy, but right now,” she clarifies, “it is the pain that is most bothersome. When I have to miss work or have trouble caring for my children it makes me feel incredibly guilty. If I could just get the pain under control, I would feel better.”
When Dr. Barnett inquires if she is planning on having any more children, Ms. Tomlin indicates that she has not discussed that with her husband. Dr. Barnett suggests that if she considers getting pregnant again he would like to see her for a preconception appointment.
Dr. Barnett recommends Ms. Tomlin take ibuprofen to decrease the effect of prostaglandins, and hence decrease cramping. Ms. Tomlin wonders, “I tried it once in a while but am not sure it helped.”
” I’d like you to take the ibuprofen regularly when you have your periods. Does this sound like something you would like to try?” Ms. Tomlin agrees to try it.
“There is also the option of taking birth control pills to decrease the cramping,” Dr. Barnett begins, but Ms. Tomlin interjects that she does not want to use hormones since they’ve made her vomit in the past.
Dr. Barnett explains that he would also like to get some bloodwork and order a pelvic ultrasound to look at her uterus more closely. Ms. Tomlin leaves with the plan to return after two periods so she can see if the ibuprofen has helped with her symptoms.
RETURN VISIT AND LAB RESULTS
Two months later, you see Ms. Tomlin is on the schedule and ask to see her. Dr. Barnett replies, “That is a great idea! Continuity is one of the keys to therapeutic relationships in family medicine.”
He tells you that he spoke with Ms. Tomlin after her ultrasound result came back. She seemed to understand the results over the phone but was waiting for two full menstrual cycles to follow up about treatment. You also see she did something called an ‘SBIRT’ and want to know more.
You take a few minutes to review the results of the studies you requested at Ms. Tomlin’s last visit.
Studies
Thyroid-stimulating hormone: 2.5 μIU/mL (2.5 mIU/L)
Human chorionic gonadotropin: (HCG) negative
complete blood count:
- White blood cell count 8.0 cells x 103/μL (8.0 cells x109/L)
- Hemoglobin 11.5 g/dL (115 g/L)
- Hematocrit 35% (0.35)
- Platelets 250,000/mm3 (250 x109/L)
- Pelvic ultrasound: Three fibroids in the uterus. One serosal measuring 2 x 2.5 x 1.5 cm. The other two intramural, measuring 3 x 2 x 2.6 cm and 4.3 x 5.2 x 4.5 cm. Ovaries: normal in size and appearance without cysts. No pelvic free fluid.
SBIRT: PHQ-2 and alcohol screen negative. “3” noted as response to “how many times in the last year have you used a recreational drug or used a prescription drug for nonmedical purposes?”
THERAPEUTIC OPTIONS
You greet Ms. Tomlin and start by asking her how she is doing, remembering that open-ended questions are the best method to start the interview. She replies, “Well, I have had two periods since the last time I was here. The cramping is better, but I still had to miss work one day last month because the diarrhea and cramping were so bad and I needed to take pain medications.”
You then begin to ask more direct questions.
“How have you been doing with the ibuprofen?”
“I took it three times a day like you said. At first, I felt nauseated but then I remembered to eat with it so that was better. Sometimes I would forget the dose in the middle of the day while I was at work, but I took it as scheduled the majority of the time. My husband had a back injury, though, and I noticed using oxycodone helped even more.”
“Did ibuprofen make your pain any better?
“The pain is a little better with ibuprofen.”
‘How much did your pain change before and after the ibuprofen or oxycodone? I want to be sure we come up with the safest option for you and a 1-10 scale may help us.”
“I guess the pain used to be eight or nine on bad days when I saw you last time. Now it is about a three every day of my period except for those two really bad days where it is a five or six, when the oxycodone takes it down to a two.”
Considering Ms. Tomlin’s history, which is the best treatment option at this time for her diagnosis?
F. Progesterone-releasing intrauterine device
DISCUSSING TREATMENT
You report to Dr. Barnett that the scheduled ibuprofen is working but not as well as Ms. Tomlin would like, concluding, “I think she has secondary dysmenorrhea due to leiomyomas. Since she is still planning to have children her best options are combined hormonal contraceptives or the progesterone-releasing IUD. This may also help her avoid the urge to take pain medications by relieving her discomfort.”
You and Dr. Barnett return to discuss these options with Ms. Tomlin. You start, “I think it would be helpful to consider some type of hormonal treatment for your symptoms. I remember you told us that you had trouble taking the birth control pill in the past. The good news is you have a lot of other options to choose from.”
Ms. Tomlin interjects, “I don’t think I want to try any other pills. I’m really nervous about having a reaction like I had before with pills. How do these other treatments work?”
You explain how other hormonal therapies are used and pull up the website http://www.bedsider.org/methodsand go over the information on the page.
When you mention the medroxyprogesterone shot, Ms. Tomlin tells you, “I had a friend who used ‘the shot’ and she gained 30 pounds. I definitely don’t want to try that!”
“I understand,” you assure her. “Beyond this, the other options are all procedures or surgeries. I think one of the options I have just given you is best to start. Which would you like to consider?”
Ms. Tomlin asks, “How much does the IUD cost? I am not sure if my insurance covers it.” Dr. Barnett tells her that the typical patient cost is about $845. He advises her to call and see if her insurance covers the actual IUD and the appointment to place it. He also advises her that many insurances cover it for the heavy bleeding she is experiencing.
Ms. Tomlin decides to try the progesterone-releasing IUD. You arrange a follow-up in two weeks to place the IUD. You recommend she takes 600 mg of ibuprofen prior to the appointment to help with cramping.
RETURN VISIT
It is two weeks later, and Ms. Tomlin has just arrived for her progesterone-releasing IUD placement. She tells you she is currently having her period. You explain to her that this is fine because it can, in fact, be easier to place the IUD while she is bleeding since the cervix is open a little.
Mrs. Tomlin says, “I have to be honest with you. This last period my mood was uncontrollable. I was crying all of the time and yelling at my children every day. It really bothers me, so we threw out all of the oxycodone at home, too.”
You remember all of the symptoms you considered three months ago at her first visit when you spoke about premenstrual syndrome, and remember a recent documentary on the opioid crisis.
You ask a few more questions:
“I just want to be certain nothing else is going on. Have you had any problem with your appetite, weight, or your sleep?”
“No problems with my appetite or weight. I am only tired when I stay up too late. But I never have problems sleeping.
“How has your energy been; are you enjoying life and having fun?”
“I guess my energy is normal. Mostly I enjoy my life. The kids are frustrating at times, but we have fun together. My husband and I just went out on a “date” last weekend. So, yeah, I feel like things are good.
“Have you ever thought of hurting yourself or anyone else?”
“Heavens, no.”
FINALIZING PLAN
In his office, you explain to Dr. Barnett, “It seems as if Ms. Tomlin does have some problems with her mood changing and irritability during her period. It doesn’t sound like she had any problems stopping the oxycodone, which is great. No other new problems have come up, but remember she does get some bloating, fatigue, and one day of diarrhea. I wonder if she does have premenstrual syndrome. I asked her some screening questions for depression, and she doesn’t have any issues with sleeping or appetite changes. She is not suicidal and does not have anhedonia.”
Dr. Barnett recommends looking into this more with follow-up.
Which of the following are effective treatments for premenstrual syndrome?
A. Danazol
C. Oral contraceptives
D. Selective serotonin reuptake inhibitors (SSRIs) during menses
IUD PLACEMENT
The two of you and a chaperone enter the exam room. You explain the procedure to Ms. Tomlin. She has no questions and signs the consent form in front of you, Dr. Barnett, and the chaperone.
After Dr. Barnett has inserted the IUD when Ms. Tomlin is sitting again, Dr. Barnett inquires, “Ms. Tomlin, I understand your mood is up and down around your period?”
After her affirmative reply, he tells her, “This type of treatment for your bleeding may also be helpful for those symptoms. We will have to see over the next two or three months. If you do not think things are better, please come back and let’s discuss other options. Think about asking someone close to you about their observations, as sometimes friends and family can provide useful information about your mood that you may not be aware of yourself.”
Ms. Tomlin agrees.
PHONE FOLLOW-UP
Three months after Ms. Tomlin had her IUD placed, you ask Dr. Barnett about Ms. Tomlin.
Dr. Barnett replies, “You know, she never returned. I wonder how she is doing. Why don’t you call her and see how the IUD is working.”
You call Ms. Tomlin and ask her how things have been going since the IUD was placed.
“I am so sorry I did not come back,” she starts. “Everything has gone fantastic. I did have a few weeks of bleeding on and off but none since. And I missed one day of work the first month for cramping, but since then, any cramping I’ve had goes away with just one tablet of ibuprofen and no other medications! I know I should have come back to have the strings checked, but I can feel them fine when I check myself. Almost everything has gone away. I do still get moody and cry sometimes with my period, but it is tolerable. I can deal with the diarrhea, too, for now. This was the best option for me.”
“I am glad that it worked for you. I will let Dr. Barnett know,” you reply.
Dr. Barnett overhears the final part of your conversation. “I guess she is doing well,” he concludes. You comment how much easier it is to care for Ms. Tomlin now that you have seen her a few times and know her. He agrees wholeheartedly.
He asks,
“Is there anything else you think should be done for her this year during her physical?”
“She will not need a Pap yet. Since she has never had an abnormal Pap test, has one male sexual partner, and is over the age of 30, I think the frequency can be decreased to every five years. She is not old enough for mammograms or other cancer screening at age 33. So maybe just checking in again about her plans to have children and her recent opioid use. And of course, checking whether she is up to date on her immunizations!” you explain to him.
Dr. Barnett agrees and you turn your conversation to the next patient.
